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Intraoperative Cholangiography and Risk of Common Bile Duct Injury During Cholecystectomy
David R. Flum, MD, MPH;
E. Patchen Dellinger, MD;
Allen Cheadle, PhD;
Leighton Chan, MD, MPH;
Thomas Koepsell, MD, MPH
JAMA. 2003;289:1639-1644.
Context Intraoperative cholangiography (IOC) may decrease the risk of common bile duct (CBD) injury during cholecystectomy by helping to avoid misidentification of the CBD.
Objective To characterize the relationship of IOC use and CBD injury while controlling for patient and surgeon characteristics.
Design, Setting, and Patients Retrospective nationwide cohort analysis of Medicare patients undergoing cholecystectomy from January 1, 1992, to December 31, 1999. Patients were identified using Current Procedural Terminology codes from the Medicare Part B depository. Common bile duct injury was defined by a second surgical procedure to repair the CBD injury within 1 year of cholecystectomy. Surgeon demographic features were obtained from matching the Medicare Part B data to the American Medical Association Physician Masterfile database.
Main Outcome Measure Frequency of CBD injury in patients who did and did not have IOC performed during cholecystectomy, controlling for patient-level (age, sex, race, and case complexity) and surgeon-level (surgeon's age, sex, race, year of surgical procedure, case order, percentage of IOC use in prior surgical procedures, years in medical practice, board certification, and specialization) factors.
Results The database search identified 1 570 361 cholecystectomies and 7911 CBD injuries (0.5%). Common bile duct injury was found in 2380 (0.39%) of 613 706 patients undergoing cholecystectomy with IOC and in 5531 (0.58%) of 956 655 patients undergoing cholecystectomy without IOC (unadjusted relative risk, 1.49; 95% confidence interval, 1.42-1.57). After controlling for patient-level factors and surgeon-level factors, the risk of injury was increased when IOC was not used (adjusted relative risk, 1.71; 95% confidence interval, 1.38-2.28). While surgeons performing IOCs routinely had a lower rate of CBD injuries than those who did not, this difference disappeared when IOC was not used.
Conclusions In this study of Medicare patients undergoing cholecystectomy in the 1990s, the risk of CBD injury was significantly higher when IOC was not used. Although IOCs may not prevent all CBD injuries, this study suggests that the routine use of IOC may decrease the rate of CBD injury.
Author Affiliations: The Robert Wood Johnson Clinical Scholars Program (Drs Flum and Koepsell), the Departments of Surgery (Drs Flum and Dellinger), Health Services (Dr Cheadle), and Rehabilitation Medicine (Dr Chan), University of Washington; and the Division of Clinical Standards and Quality, Centers for Medicare and Medicaid Services Region 10 (Dr Chan), Seattle, Wash.
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